Key Messages

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Topic 5: Early childhood trauma and therapeutic parenting

• Young children seek proximity and comfort from their primary caregivers. When this is not available as a result of maltreatment, children experience chronic stress, which affects the development of the brain.
• Maltreatment also affects children’s attachment and can result in insecure or disorganised attachment.
• Children arrive in their placements with established behaviour patterns, based on their relationships with their previous caregivers.
• Carers need to understand their children so they can offer sensitive and reflective parenting to help their recovery. Successful care requires emotional attunement, creativity and a willingness to understand how the world feels from the child’s perspective.
• Foster carers and adopters need support and training to cope with the complexity of caring for children who have experienced trauma.

Physiological response to maltreatment

Maltreatment can take many forms (eg physical, emotional and sexual abuse, emotional and physical neglect). Whatever form it takes, the child experiences the kind of caregiving in which key nurturing experiences are missing, leading to developmental impairments (Howe, 2009).

Normally, when children feel frightened or in need they seek proximity with their primary caregivers. These biologically programmed behaviours are the basis for forming attachments, and also help to shape brain development. Children whose needs are met by sensitive and available caregivers learn to trust and develop secure attachments (Howe, 2009).

Children who experience abuse experience caregiving that is frightening. They seek proximity to the caregiver who is also a source of fear, inducing even more anxiety. Caregivers who frighten their children are not available to help them feel safe and regulate their distress (Howe, 2009).

Children who have been physically or emotionally neglected learn that their fears and needs are not tended to by their caregiver. As a result of this neglect, they lack emotional attunement and regulation and tend to cry and remain distressed for longer periods of time than children who have not been neglected (Howe, 2009).

When a child’s needs are not met by the primary caregivers, the body’s physiological system becomes activated and releases the ‘stress hormone’ cortisol. Acute stress experienced over a prolonged period can have a negative impact on the physiology of the brain (Woolgar, 2013), including those parts of the brain that are responsible for planning and reasoning, as well as self-regulation and mood and impulse control. Damage caused by chronic stress can impede the development of these skills and has consequences for future learning, behaviour and health (Brown and Ward, 2013). (For more information, see briefing 4 on ‘Early brain development and maltreatment’.)

The continuing plasticity of the brain, however, allows appropriate therapeutic work to be done, enabling the child to become less impulsive and more engaged in relationships. High-quality nurturing care and other positive experiences can help repair earlier damage (Woolgar, 2013; Schofield and Simmonds, 2011).

Maltreated children and attachment

Children’s prior experiences shape their behaviours. This means they arrive in their placements with established behaviour patterns based on their relationships with their previous caregivers. These behaviour patterns are adaptive strategies that helped them to cope in adverse situations. When they are placed with foster carers or adopters, however, many children transfer the behaviours, feelings and responses they experienced with their birth parents to their new carers (Howe, 2009).

Maltreated children may have developed attachment patterns that are:

• Avoidant – this manifests itself as self-containment, over-regulation of emotions and shutting down feelings. Foster carers or adopters may react to this by deactivating their caregiving or ignoring the children. For these children, carers need to be consistent and responsive to allow the child to feel safe and less anxious when they need care and protection.
• Ambivalent – children develop exaggerated and attention-seeking behaviours. When placed with substitute carers, they continue to make demands and have a strong need to be recognised, loved and approved. Carers may feel unable to meet the child’s needs and can become exhausted. For these children, carers need to provide a predictable environment to reduce the child’s anxiety and build trust in the carer’s availability.
• Disorganised – this form of attachment occurs in 80 per cent of children who have been maltreated. Children show a range of controlling behaviours such as bossiness or compulsive caregiving, which can lead to sudden rage in stressful situations and behaviour that is out of control. These children react very quickly to attachment-related stimuli, swinging between fear, aggression, rage, depression and helplessness. When placed with foster carers or adopters, they avoid being vulnerable or dependent and try to remain in control by being bossy, angry, derogatory or aggressive. Carers need to understand the origins of these behaviours to help them overcome their own feelings of helplessness and anger (Howe, 2009; Brown and Ward, 2013). (See also briefing 2 on ‘Attachment theory and research’.)

Therapeutic parenting for developmental recovery

Adopted and fostered children are likely to have experienced trauma on a number of levels: from earlier abuse and neglect as well as from the separation and loss of their birth family. This trauma can lead to emotional, behavioural and educational difficulties (Pennington, 2012).

Children’s responses to traumatic events vary. For some, the ‘fight or flight’ response is activated and they become hyperaroused (demonstrated through hypervigilance, anxiety and panic). For others, fighting or fleeing is not possible so the child ‘freezes’ and uses avoidant ‘fleeing’ mechanisms that are dissociative. Examples of a dissociative state include a distorted sense of time and a detached feeling of observing oneself. In extreme cases children may withdraw into a fantasy world (Perry, 2003).

Traumatised children need to be helped to work through their trauma as they may continue to experience the neurological, developmental and psychological impact from their early histories even when they are placed with a supportive and loving family. Traditional parenting techniques may not work with these children and foster carers and adopters need to develop alternative therapeutic parenting techniques to help build their resilience (Pennington, 2012).

Children who have been abused or neglected are likely to have developed strategies for staying safe that involve not letting carers get in control. As a result, they resist being protected and cared for by substitute carers. They may show a range of controlling behaviours that help them to feel they are in charge of their own care and protection. This can annoy and upset adults who are trying to care for the child and can make them become authoritarian or aggressive. This serves to confirm to the child that they should not let down their defences and that they need to remain in control (Howe, 2009).

Parenting children with histories of abuse and neglect requires sensitive caregiving. The more carers understand about the impact of abuse and neglect on children, the more likely they are to offer nurturing care (Howe, 2009).

Carers need to understand their children and commit themselves to a mindful relationship with the child so that they can offer sensitive and reflective parenting to help their recovery. Successful care requires emotional attunement, creativity and a willingness to understand how the world feels from the child’s perspective. The children need caregivers who will both co-regulate with them and teach them to manage their anxieties (Howe, 2009; Cairns, 2006).

Schofield and Beek (2009, 2014) provide a framework for therapeutic parenting (The Secure Base Model) that helps children move towards greater security and resilience. It focuses on the interactions between caregivers and children and is based around five caregiving dimensions:

• availability – helping the child to trust
• sensitivity – helping the child to manage feelings and behaviour
• acceptance – building the child’s self-esteem
• co-operation – helping the child to feel effective
• family membership – helping the child to belong (Schofield and Beek, 2014).

Schofield and Beek suggest the model can be used:

• when children are in need or at risk
• at the beginning of a fostering or adoptive placement
• as part of routine supervision of foster carers
• when placements are in difficulty.

Schofield and Beek provide a number of examples of positive caregiving approaches to help children recover:

Supporting foster carers and adopters

Parenting a traumatised child can involve high levels of stress. These parents need appropriate support to help them care for their children and to help them make sense of their children’s behaviour (Pennington, 2012). Foster carers and adopters may struggle to maintain a positive attitude. Social workers need to be alert to this possibility and avoid reinforcing these negative feelings.

Research suggests that foster carers need support in the following areas:

• close links with family placement social workers
• clear and consistent communication between fostering teams and foster families
• access to out-of-hours and other professional support services
• feeling part of a wider team supporting a child. (McDermid et al, 2012)

Adopters also need support, but all too often this is lacking (Pennington, 2012). They feel that more information needs to be provided about support from the beginning of the adoption process.

There are a number of publications on parenting that can be recommended to adopters and foster carers, including:

It is essential that foster carers and adopters are able to access timely, relevant and good-quality learning to help them provide a specialised level of care to their children (Clarke, 2009). Carers may also need to access specialist interventions (see below) or CAMHS. Social workers need to ensure there is a timely assessment of the child’s needs by appropriately skilled specialists, and that specialist support is provided where needed.

Evidence-based interventions

Some children will require more intensive interventions to help them recover from their early trauma. A number of evidence-based programmes have been found to be effective in improving outcomes for looked after children and young people. At the core of these programmes is an approach based on working intensively with the young person in the context of their birth or carer family situation. The programmes share a number of features including: engagement with the child and parents/carers; developing positive family relationships; promoting pro-social peer relationships; improving parenting skills; and providing clear and consistent behavioural boundaries.

These programmes include:

• Multi-dimensional Treatment Foster Care (MTFC) for children and young people experiencing significant levels of difficulty in several areas of their lives.
• Keeping Foster and Kinship Parents Trained and Supported (KEEP), which aims to increase the parenting skills of foster and kinship carers of children aged 5 to 12 years.
• Fostering Changes, which enables foster carers to respond more appropriately to children and young people.

AdOpt is a group parenting programme for adoptive parents to address specific difficulties that adopted children may present.

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Key questions for the child’s social worker

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DfE Topic 5 Early childhood trauma and therapeutic parenting exercises 02/04/14 .DOC

Methods
Suitable for self-directed learning or reflection with a colleague or supervisor.

Learning Outcome
Review your understanding of trauma and identify actions you can take to support the children you work with.

Time Required
45 minutes review and 30 minutes reflection.

Process
Thinking of your current approach, answer the following questions:

• What steps do you take to gather the fullest possible information concerning the trauma and nurture history of individual children – from the birth family, the child’s medical, social work, police, education and other professionals?
• What steps do you take to ensure that the child’s carer and all members of the team have an understanding of the child’s history, the effects of trauma on the child and his or her attachment profile?
• What is your understanding of the impact of maltreatment on child development and attachment? (See Briefing 2 on ‘Attachment theory and research’ and 4 ‘Early brain development and maltreatment’).

Key questions for the supervising social worker

Methods
Suitable for self-directed learning or reflection with a colleague or supervisor.

Learning Outcome
Review how you support foster carers and adopters to provide therapeutic parenting and identify actions you can take to support them.

Time Required
Two sessions of 45 minutes.

Process
Thinking of your current approach, answer the following questions:

• How does the team support foster carers and adopters to provide a therapeutic environment conducive to recovery, for instance regular routines, consistent boundaries etc?
• What steps do you take to facilitate access to specialist services?
• What steps do you take to identify the attachment styles of foster carers and adopters to ensure that attachments are compatible and relationships are not compromised?
• Are foster carers and adopters offered training that is evidenced-informed? How do you follow up training to help carers integrate what they have learned into everyday practice?
• What evidence do you have that training is influencing foster carers’ and adopters’ practice? How do you evaluate the impact of training on everyday practice?

Key questions for foster carers and adopters

Methods
Suitable for discussion with a social worker or as a group discussion.

Learning Outcome
Review the information and support you receive to provide therapeutic parenting support and identify how you can access additional information or support.

Time Required
Two sessions of 45 minutes.

Process
Thinking of your current situation, answer the following questions:

• How do you ensure that you have a full picture of the child’s history?
• How do you rate your understanding of child development and attachment and the impact of abuse and neglect on these?
  • Which areas would you like to know more about?
  • What training and development opportunities are available to help you understand the behaviour of traumatised children and to assist you in parenting them?
• What are the key components in developing a constructive relationship with your social worker?
• How do you ensure that your supervision helps you integrate your learning into everyday practice?
• In view of the complex needs of children who are placed for adoption, what training and support do you need once the child is adopted?

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Promoting effective attunement with the child – Exercise

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Early childhood trauma Final PDF 02.04.14

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05. Early childhood trauma questions and exercises as a Word DOCX file 02/04/14
Download the questions and exercises as a Word 97-2003 DOC file:
DfE Topic 5 Early childhood trauma and therapeutic parenting exercises 02/04/14 .DOC

To help carers promote recovery the principles as described in the table below can be adapted to meet the developmental needs of all age groups (Cairns, 2013). It provides a helpful framework for the team to use in supporting carers to build an environment to promote affective attunement with the child.

Examples of interventions to promote affective attunement (Cairns, 2013, adapted)

Exercise

The aims of therapeutic parenting are to help children regulate stress, to learn how to relate differently to others and to promote attachment. New neurological patterns are gradually established that are stimulated by various types of interactions and activities that compensate for the lack of attunement in their early years (Cairns 2013)

Using the Sereta, Tia and Paulo case study and the table as a framework what activities would be appropriate for this sibling group taking into account their developmental age as well as their chronological age.

Audience

• Foster carers
• Adopters
• Child’s social worker
• Supervising social workers
• Adoption social workers
• IROs

Cairns, K. (2013) Attachment, trauma and resilience: Therapeutic caring for children, 8^th edition, London: BAAF

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Presentation slide deck

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Presentation Slides for this topic as a PDF file (available soon)

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DfE Topic 5 Early childhood trauma and therapeutic parenting PowerPoint slides ver97-2003_SB030414

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References

Download these notes as a PDF:
Early childhood trauma Final PDF 02.04.14

• Brown R and Ward H (2013) Decision-making within a Child’s Timeframe. London: Childhood Wellbeing Research Centre, Institute of Education
• Cairns C (2006) Attachment, Trauma and Resilience: Therapeutic Caring for Children. London: BAAF
• Clarke H (2009) Learning as they Go: Accessing ongoing learning and development opportunities. Findings of a survey of foster carers in the UK. London: The Fostering Network
• Howe D (2009) ‘The impact of histories of abuse and neglect on children in placement’ in Schofield G and Simmonds J (eds) The Child Placement Handbook. London: BAAF
• McDermid S, Holmes L, Kirton D and Signoretta P (2012) The Demographic Characteristics of Foster Carers in the UK: Motivations, barriers and messages for recruitment and retention. London: Childhood Wellbeing Research Centre, Institute of Education
• Pennington E (2012) It Takes a Village to Raise a Child: Adoption UK survey on adoption support. Banbury: Adoption UK
• Perry B (2003) Effects of Traumatic Events on Children. The ChildTrauma Academy
• Schofield, G. and Beek, M. (2009) Growing up in foster care: providing a secure base through adolescence. Child and Family Social Work, 14, 255-266
• Schofield, G. and Beek, M. (2014) The Secure Base model: promoting attachment in foster care and adoption. London: BAAF
• Schofield G and Beek M ‘Providing a Secure Base – The Secure Base Model’ Centre for Research on the Child and Family, University of East Anglia (accessed 8 February 2014)
• Schofield G and Simmonds J (2011) ‘Contact for Infants Subject to Care Proceedings’ Family Law (41) 617-622
• Woolgar M (2013) ‘The Practical Implications of the Emerging Findings in the Neurobiology of Maltreatment for Looked After and Adopted Children: Recognising the diversity of outcomes’ Adoption and Fostering 37 (3) 237-252

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